In the recovery room, if a woman is asked to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, she is most likely being tested to see whether she:
Has regained some flexibility.
Has hidden bleeding underneath her.
Is a candidate to go home after 6 hours.
Has recovered from epidural or spinal anesthesia.
The Correct Answer is D
hoice A rationale
While the maneuvers require muscle use, the primary purpose is not to assess flexibility, which relates more to joint range of motion and tissue extensibility. The maneuvers specifically target the major muscle groups (quadriceps, gluteal, and lower extremity muscles) innervated by the spinal nerves affected by regional anesthesia.
Choice B rationale
These leg and buttock raising maneuvers are not the most effective or direct way to detect hidden bleeding (e.g., retroperitoneal or subperitoneal hematoma) which is usually assessed by vital sign changes (hypotension, tachycardia) or specific physical findings like a fundal assessment or examination of the incision/perineum.
Choice C rationale
The determination of eligibility for a 6-hour discharge (an early discharge protocol) is based on a comprehensive set of criteria, including stable maternal and neonatal vital signs, minimal bleeding, pain control, and established feeding. While recovery from anesthesia is a factor, these maneuvers only assess neurological recovery and are not the sole determinant.
Choice D rationale
Epidural and spinal anesthesia temporarily block sensory and motor nerve impulses in the lower spinal segments. The ability to perform these specific, coordinated, and voluntary movements (Straight Leg Raise, leg flexion, and Hip Bridge/Raise) indicates the motor block has resolved and sensation is returning, confirming recovery from the regional anesthesia. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Voiding clear, pale urine three times in 12 hours is an appropriate sign of adequate fluid intake and renal function in a newborn. The normal range for voids in the first 24 hours is often at least one, and by day three, six to eight voids are expected. This output does not prevent early discharge as it suggests proper hydration and patent urinary tracts.
Choice B rationale
A birth weight of 3000 g is within the average range for a term newborn (typically 2500 to 4000 g). Weight alone, if within normal limits and stable, is not a factor that would delay discharge. Significant weight loss (over 10% of birth weight) or a weight below 2500 g is more concerning.
Choice C rationale
Significant difficulty with latching and sucking during two initial breastfeeding attempts could indicate problems with the infant's feeding readiness, coordination of suck-swallow-breathe reflex, or maternal technique. Establishing effective feeding is a key criterion for early discharge to ensure adequate caloric intake and prevent hypoglycemia or dehydration.
Choice D rationale
Passing one meconium stool within the first 12 hours of life is a normal and expected finding, indicating a patent anus and gastrointestinal tract function. Meconium passage typically occurs within the first 24 to 48 hours, and this finding is reassuring for discharge. —.
Correct Answer is D
Explanation
Choice A rationale
While drying does remove blood and amniotic fluid, the primary scientific rationale is thermoregulation. Removing superficial contaminants is secondary to preventing cold stress. Allowing the wet skin to air dry would cause rapid, dangerous cooling, a more significant threat than the mere presence of maternal blood.
Choice B rationale
The drying and vigorous stimulation do not specifically increase blood flow to the distal extremities (hands and feet). The initial drying is the first step in preventing evaporative heat loss, which is paramount to maintaining the infant's core body temperature and promoting stable transition to extrauterine life.
Choice C rationale
Stimulating the infant by rubbing the back or soles of the feet does encourage crying, which helps expand the lungs and clear fluid. However, the most immediate and critical scientific reason for thorough drying is to prevent significant evaporative heat loss, which accounts for a large percentage of neonatal heat loss.
Choice D rationale
Water on the skin surface rapidly evaporates, and because a significant amount of heat is required to change water from liquid to vapor (latent heat of vaporization), this evaporation causes rapid and significant body heat loss. Thorough, immediate drying eliminates the largest source of cold stress for a newborn, preventing a drop in core temperature.
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